OCD can be scary and frustrating for its sufferers, family members, and friends. People with OCD have intrusive, undesired thoughts, worries, or superstitions so excessive that they cause significant life distress or disruption. Common obsessions include imagining having harmed other people, having intrusive, unwanted sexual thoughts, and fears of contamination. Others may fear losing control or succumbing to violent urges, have excessive religious or moral doubts, fear forbidden thoughts, or may have a need to have things "just so." People with OCD may spend hours each day performing behavioral or mental rituals to temporarily quell their anxiety. Most people with OCD recognize that their fears are irrational, yet still feel unable to resist the obsessions and compulsions.
Exposure and Response (Ritual) Prevention
Cognitive-behavior therapy (CBT) is a type of psychotherapy that has been shown to be highly effective for OCD. The goal of CBT is two-fold: to change thoughts and behaviors. The cognitive portion involves the identification and analysis of unhelpful and unrealistic thoughts, which are then challenged. In the behavioral portion, the therapist and client work together to change the compulsive behaviors. This typically includes techniques such as Exposure and Response Prevention, also called Exposure and Ritual Prevention (EX/RP). In the exposure piece of the treatment, patients repeatedly expose themselves to their fears. By facing their obsessions in a systematic order, without performing compulsions, the person learns that there is nothing to fear and the obsessions begin to fade away.
Treatment of OCD with Ex/RP is typically completed in 10-20 individual therapy sessions that are roughly 90 minutes each. Ex/RP treatment emphasizes a behavioral approach to this disorder that involves exposure therapy and ritual prevention. These sessions involve gradual exposure to one's feared thoughts and situations, while the patient learns to control their compulsive behaviors such as washing and checking.
Treatment programs for children and adolescents with OCD follow the same exposure and ritual prevention approach as our programs for adults. However, the treatments are modified to take into account the developmental status of the child and, where beneficial, parents are encouraged to work actively with the child on therapeutic tasks. Age appropriate metaphors and examples are used to help the child understand the rationale for therapy, and the length and frequency of treatment sessions may be changed to conform to the needs of the child.
Eligibility for the OCD treatment is determined through an extensive interview with one of the clinicians. A complete evaluation of OCD and related symptoms includes a thorough discussion of treatment options, and recommendations. Treatment also depends on insurance, some insurance companies won't pay for longer sessions and out of the office sessions.
Components of EX/RP
In Vivo Exposure.
Exposure is the cornerstone of EX/RP treatment. In vivo exposure has been shown to reduce obsessions and related distress. This technique involves repeated and prolonged confrontation with situations that cause anxiety. The immediate goal is for the patient to remain in the situation long enough to experience some reduction in anxiety and to realize that the feared "disastrous" consequences do not occur.
Typically, exposure is gradual and the patient begins by facing objects and situations that result in only moderate levels of anxiety.
In some cases it is not possible to construct an in vivo exposure to a patient's fear, and in these instances an exposure can be done in the imagination. To conduct an imaginal exposure, the therapist and patient develop a detailed scene together based on the patient's worst fear. The exposure is typically recorded to facilitate repeated listening as homework.
The ritual or response prevention component involves instructions for the patient not to engage in compulsions or rituals of any sort. This is important because patients perceive that the rituals prevent the occurrence of a feared outcome. Only by stopping the rituals do patients learn that rituals do not protect them from their obsessional concerns. The implementation of ritual prevention involves a detailed analysis of all compulsions or rituals performed by the patient. Typically, patients are asked to keep daily logs of all rituals performed.